Simple Online Doctor

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Patient Notice! This questionnaire forms the basis of your weight loss consultation today. We need you to be honest with your answers including any current medication you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medicinal information provided before using your treatment.

1About You

Recommended Reading >>> Weight Loss

Are you aged between 18-65? *

NoYes

Unfortunately, we are unable to provide you with this medication as it may not be appropriate for you. We recommend you discuss alternative treatment options with your GP.

ID and age verification are required prior to receiving treatment.

Please enter your height (cm) *

Please enter your weight (kg) *Your weight must be from the last 7 days* *

Please note, we may contact you to ask you to provide evidence of your current weight

BMI

Do you have any weight-related medical conditions? Please see below for examples of weight-related conditions:

Non-alcoholic fatty liver disease
Non-alcoholic steatohepatitis (NASH)
On treatment for Depression linked to your weight
Cardiovascular disease (such as heart attack, Atrial Fibrilation)
Knee or hip osteoarthritis
Asthma
COPD
Obstructive sleep apnoea
Pre-diabetes
Polycystic ovary syndrome (PCOS)

NoYes

Please list your condition(s). *

Are you currently using any weight loss medication? *

Where were you prescribed Xenical / Orlistat before? (E.g. private GP, different online pharmacy) *

Has Xenical / Prolistat (Orlistat) helped with your weight loss? Please describe any side effects you have experienced from taking this medicine. *

Please tell us which other weight loss medication you are using: *

2Your health

Are you currently taking any of the following medication?

Ciclosporin
Warfarin
Antiepileptic Medication
Antiretrovirals
Acarbose
Amiodarone

NoYes

Are you currently taking any prescription-only medicines, over the counter medicines, alternative medicines or recreational drugs? *

NoYes

Please list any prescription, over the counter or alternative medicines you are taking, including the dose. *

Do you have any known allergies? *

NoYes

Please provide more information below. *

Do you have any history of kidney or liver conditions? *

NoYes

Please provide more information below. *

Have you ever been diagnosed with chronic malabsorption syndrome? (problems with absorbing your food) *

NoYes

Please provide more information below. *

Have you ever made yourself sick (vomit) to control your shape or to lose weight? *

NoYes

Have you ever taken laxatives in order to lose weight? *

NoYes

Do you worry that you have lost control over how much you eat? (i.e. you have eaten an unusually large amount of food and have had a sense of loss of control at the time?) *

NoYes

Would you say that food or image dominates your life *

Do you ever eat in secret? *

NoYes

Have you ever been diagnosed with gallbladder, bile duct or pancreas disease? *

NoYes

Please provide more information below. *

Have you ever been diagnosed, or do you currently suffer with an eating disorder such as anorexia or bulimia? *

NoYes

Please provide more information below. *

Are you pregnant, planning to become pregnant or breastfeeding? *

NoYes

Please provide more information below. *

3Consent

Do you understand that Orlistat will not work alone. For best results, this medication must be combined with a weight management plan, and regular exercise. *

Confirm

Do you understand that side effects (particularly oily stools), may be more likely if you have a high fat diet. Fat should take up no more than 30% of your calorie intake. *

Confirm

I understand that it is recommended to take a multivitamin supplement containing the fat soluable vitamins A, D, E and K whilst being treated with Xenical / Prolistat (Orlistat). These should be taken 2 hours after my Orlistat dose or at bedtime. *

Confirm

I confirm I am over 18 years old.

The medicine ordered is for my sole use only.

I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.

I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.

I agree to the Simple Online Doctor terms and conditions. *

Confirm

We strongly advise that you inform your GP of any treatment you receive.
Would you like us to inform them on your behalf? If you are unsure, you can search your GP clinic information by clicking here.

NoYes

Please enter the email address of your GP clinic *

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